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Adopting a more judicious, decision-oriented approach on lab tests for dyslipidemia, the U.S. Departments of Defense (DoD) and Veterans Affairs (VA) are recommending that patients repeat nonfasting lipid profiles just once every 10 years, ceasing any tests once they achieve statin dose goals. DoD and VA also recommend against routine fasting before lipid testing and coronary artery calcium (CAC) testing or additional risk markers, unless a consultation takes place first.
“All lab testing should have an intentional purpose that’s clearly communicated to patients prior to testing. This communication should clearly include the uncertainties of its usefulness, and its relative value,” Patrick G. O’Malley MD, MPH, FACP, professor of medicine at Uniformed Services University in Bethesda, Maryland, and the guidelines’ corresponding author, told CLN Stat.
The VA and DoD have been collaborating on clinical practice guidelines for more than 20 years, O’Malley said. “Our practice is to update guidelines every 5 years, and so this guideline is updating the prior guideline from 2015.” The VA/DoD Evidence-Based Practice Work Group’s 27 recommendations on managing lipid levels and reducing cardiovascular disease (CVD) risk were published in the Annals of Internal Medicine.
The new guidelines share similarities with American College of Cardiology/American Heart Association recommendations on dyslipidemia. But the DOD/VA’s emphasis on fewer tests is a key difference, O’Malley said. “Our focus is less on targeting [low-density lipoprotein] goals in treatment, and more on reaching the target dose of statins to comport more closely with clinical trials which have proven their efficacy,” he explained. “Second, our orientation is more to guide primary prevention to address the problems of undertreatment and overtreatment of lipids for CVD risk reduction, and to reinforce the guidance of using moderate dose statins to better align with the primary evidence.”
DOD and VA also place more emphasis on exercise and diet as a means for reducing CVD risk. “Finally, we do not recommend jumping to the most aggressive doses and treatments in secondary prevention, but rather recommend a stepwise approach that is event driven,” said O’Malley.
In its testing protocols, the work group recommends that clinicians reserve fasting measurements for uncommon circumstances, not routine use. “Fasting lipid levels add no clinical value to risk prediction compared with nonfasting levels and are considerably more burdensome in terms of patient inconvenience and cost,” they summarized.
Nonfasting lipid tests should take place only every 10 years, and patients should no longer undergo this testing once they achieve a goal statin dose. Lipids do not vary significantly over time within individuals, explained O’Malley. “They only explain a small amount of the variance in CVD risk calculators and are now measured using direct assays of subcomponents,” specifically low-density lipoproteins (LDL), he said. For these reasons, it isn’t necessary to measure lipids more than every 10 years.
The panelists also recommended judicious use of risk marker tests. CAC, high-sensitivity C-reactive protein tests, ankle-brachial index, and apolipoprotein tests should only take place after patients discuss with physicians the benefits, harms, and reasons for testing. There is insufficient evidence that these tests improve patient-centered outcomes, said O’Malley. Patients should be aware of this uncertainty before agreeing to have these tests.
The panelists also took a moderate approach to statin use. Clinicians should continue to treat to target the statin dose instead of LDL levels. “The focus for targeting statin dose instead of LDL goals was determined by clinical trial evidence that used fixed dose statins, not LDL targeting strategies,” said O’Malley.
The authors continue to emphasize moderate-dose statins as a primary preventive, but recommended against proprotein convertase subtilisin/kexin type 9 inhibitors. As a secondary preventive measure, clinicians should initially administer moderate statin doses, using a “stepwise” approach to intensifying doses in higher-risk patients, based on several factors such as the patient’s event history, safety, and cost-effectiveness.
In a related editorial, Alison L. Bailey, MD, and Charles L. Campbell, MD, questioned some of the group’s more moderate approaches, suggesting that this might lead to undertreatment of some patients in the VA/DoD population.
The recommendation against CAC scores, for example, “does not account for the growing body of observational data regarding the utility of CAC scoring for additional risk stratification, as well as the results from small trials that point toward improved outcomes among patients treated with this approach,” noted Bailey and Campbell. They also questioned VA/DoD’s concerns about the effects of high-intensity statins on mortality.
“The other guideline committees, mindful of the strong relationship between cardiovascular events and LDL-C levels, have chosen to value the wealth of evidence suggesting that high-intensity statin therapy prevents major vascular events, with a slight increase in myopathy. This view seems reasonable given the relatively low cost and low risk associated with high-intensity statin therapy,” wrote Bailey and Campbell.